More evidence on overuse of antipsychotics

So-called 'second-generation,' antipsychotic drugs were originally developed to tackle psychoses and schizophrenia but are increasingly being used to tackle unrelated conditions where cheaper and more effective alternatives exist. Researchers from the University of Chicago and IMS Health used data from a survey of U.S. physicians. They found that 16.7 million prescriptions for antipsychotic drugs were written in 2008, accounting for $10 bn, or nearly 5% of U.S. spending on prescription drugs. 9 million of the prescriptions - about $6bn across the U.S. - were for conditions where the use of the drug does not have approval from the U.S.'s Food and Drug Administration. There were particular concerns about the use of antipsychotic drugs to treat bipolar disorder and depression where cheaper and more evidence-based alternatives exist. The drugs can have a number of different side effects including weight gain, diabetes and heart disease.

New study sheds light on prescribing patterns

In the U.S. the Substance Abuse and Mental Health Services Administration has been looking into the prescription of psychiatric drugs such as antipsychotics, antidepressants and anti-anxiety drugs. The study used data from the 2005 National Disease and Therapeutic Index, a national sample of around 4,000 doctors carried out by IMS health. It found that antipsychotic drugs were only actually used for schizophrenia/psychosis just over a third (35%) of the time and were actually used more often (39%) to treat mood disorders. The drugs - which can have serious side effects - were also used to treat dementia (7.4%), anxiety (6%) and ADHD (6%). Antidepressants were mostly used to treat mood disorders (65%) but they were also used to treat anxiety (16%) and schizophrenia/psychosis (2.6%). 28% of prescriptions for anti-anxiety drugs were used for non-psychiatric problems including anxiety related to medical treatment (6%), allergic reactions (4%) and back problems (2.5%).

You can find out more about this study at

http://www.medicalnewstoday.com/articles/183073.php

The pushchair pill poppers

Toddlers in the U.S. are being prescribed powerful antipsychotic drugs and the number has doubled over the past decade. Mark Olfson from Columbia University in New York studied the records of children with private medical insurance between 2000 and 2007. He found that the number of children diagnosed with bipolar disorder and prescribed antipsychotics doubled over the course of the study. About 1.5% of all children between the ages of 2 and 5 received some sort of psychotropic drug - either an antipsychotic, a mood stabilizer, a stimulant or an antidepressant - in 2007. Of the children diagnosed with bipolar disorder about half were prescribed an antipsychotic. Antipsychotics - which can have severe side effects - were prescribed to about 1 in 3,000 2 year-olds.

http://uk.reuters.com/article/idUKTRE60E0NC20100115?feedType=RSS&feedName=healthNews&sp=true

Figures show extent of prescribing to children

Information obtained by the U.K. Conservative Party under freedom-of-information legislation has revealed the extent of drug prescribing to children for mental-health conditions. They found that in 2007 420,000 prescriptions were issued for ADHD (attention deficit hyperactivity disorder) medication - equivalent to around 35,000 children once repeat prescriptions are taken into account - up by a third since 2005. More than 113,000 prescriptions were written for antidepressants for children under 16 (equivalent to about 9,000 children) and 86,000 prescriptions were written for antipsychotics, a 7% rise since 2005.

You can read more about this story at

http://www.telegraph.co.uk/health/healthnews/6460646/Thousands-of-children-on-antidepressants.html

Recovery and medication

Recovery from serious mental illness has been described not as a "cure," but as a way of living a satisfying, hopeful, contributing life despite ongoing psychiatric disability or symptoms. Medication is an important issue for people as they think about recovery yet the relationship between the two has not been discussed that much. Researchers from the Douglas Mental Health University Institute in Montreal discussed this issue with 60 service users. For them recovery meant:

• Finding a medication that works
• Taking medication in combination with services and supports
• Complying with medication
• Having a say about medication
• Living without medication

The service users wanted to be able to communicate their concerns around medication, be supported in developing self-management strategies and have more collaborative relationships with service providers.

Piat, Myra, Sabetti, Judith and Bloom, David - The importance of medication in consumer definitions of recovery from serious mental illness: a qualitative study Issues in Mental Health Nursing 30(8), 482-490

Antipsychotics approved by FDA panel

A panel advising the U.S. Food and Drug Administration has backed the use of antipsychotic medication for children and teenagers with schizophrenia and bipolar disorder. The panel backed the wider use of the pills but had worries about the long-term effects the drugs could have on youngsters. The drugs already have combined sales of $10 billion a year but there has been little research into their long-term effects and there were also concerns that they could be used to treat other conditions such as attention deficit hyperactivity disorder (ADHD). The drugs have the side effect of weight gain and sleepiness but these symptoms need to be weighed against the damage caused by the hallucinations and delusions of schizophrenia and the extreme mood swings of bipolar disorder.

http://uk.reuters.com/article/healthNews/idUKTRE5597IC20090611?feedType=RSS&feedName=healthNews&sp=true

Lithium and psoriasis

Psoriasis is a chronic, inflammatory skin disease that is estimated to affect between 0.6% and 4.8% of the population. Lithium - which is used to treat bipolar disorder - is often linked to psoriasis and a study by researchers from Switzerland (using data from the U.K.) of 73,404 people found that long-term lithium use was associated with a small rise in the risk of psoriasis. The use of atypical antipsychotics, mainly olanzapine, was associated with a reduced risk of the skin condition.

Brauchli, Yolanda B. ... [et al] - Lithium, antipsychotics, and risk of psoriasis Journal of Clinical Psychopharmacology April 2009, 29(2), 134-140

Compliance and motivational interviewing

Non-compliance, or non-adherence (people not taking their medication) is a big worry for health professionals. This problem is particularly bad among people with schizophrenia where the rates of non-compliance are estimated at between 40-53% depending on the definition used. Motivational interviewing is sometimes used to improve compliance. It attempts to get over people's mixed feelings about changing their behaviour by bringing out their inner motivation to change. It has been used to get people with diabetes and asthma to take their medication, to treat drink and drugs problems and to get people to eat more healthily and take more exercise. Researchers from Marquette University in Wisconsin, U.S. carried out a review of studies into the effectiveness of motivational interviewing at improving compliance among people with schizophrenia. They found only five studies between 1965 and 2006. Two of them showed that motivational interviewing was effective but the other three found that it made no difference. The researchers concluded that the small sample of studies and their methodological limitations made it difficult to draw any meaningful conclusions.

Drymalski, Walter M. and Campbell, Todd C. - A review of motivational interviewing to enhance adherence to antipsychotic medication in patients with schizophrenia: evidence and recommendations Journal of Mental Health February 2009, 18(1), 6-15

Latest drug guidance

The Medicines and Healthcare products Regulatory Agency has issued its latest bulletin on the safety of drugs. This includes guidance on the use of typical (first-generation) antipsychotics in people with dementia.

You can download a copy of the guidance by clicking on the link in the title of the post.

Antipsychotics: is it time to end the generation game?

Antipsychotic drugs have usually been divided into first- and second-generation drugs with the latter being perceived as having fewer side effects than the former. Researchers from universities in Munich and Chicago looked at 150 studies comparing the effectiveness of antipsychotic drugs, which, altogether had 21,000 participants. They found that four second-generation drugs - amisulpride, clozapine, olanzapine and risperidone - were more effective than first-generation ones but that the rest were no better. When compared with the powerful first-generation drug haloperidol the second-generation drugs had less side effects but compared to other first-generation drugs there was little difference. Haloperidol - but not other first-generation drugs - produced less weight gain than most second-generation drugs. The authors called for an end to the division of drugs into first- and second-generation and an individualized treatment of schizophrenia based on efficacy, side effects and cost.

You can read more about this study at

http://psychcentral.com/news/2008/12/08/better-classification-of-psychotic-drugs-recommended/3466.html

Risperidone: longer-acting for harder cases

A depot injection is given via a long-lasting injection and aims to promote compliance in people with particularly severe mental illness, thereby enhancing relapse prevention. Risperidone is the first second-generation antipsychotic to be available in a depot format. The effects of this form of the drug have been extensively studied in trials prior to its introduction but the kinds of people who might take it have not. A Dutch study, using dispensing data from 53 community pharmacies in the north-east of the Netherlands looked to see what kind of chronic antipsychotic users switched to long-acting Risperidone. They found that the predictors for switching from an oral to a depot form of drugs were: being a man, a previous use of depot antipsychotics, recent anticholinergic drug use, and a gap in 'antipsychotic dispensation history,' i.e. a patchy history of drug-taking. Predictors of switching to depot Risperidone from a depot first-generation antipsychotic were previous use of a depot antipsychotic and consulting a specialist. The researchers concluded that compared with oral antipsychotics service users receiving a depot injection were likely to be less compliant and to suffer from worse side effects. People receiving depot risperidone as opposed to a depot first-generation antipsychotic tended to be more severely ill. The researchers concluded that the long-lasting risperidone was being used for the most severely-ill people; something that will need to be borne in mind when assessing its effectiveness.

Vehof, Jelle ... [et al] - Predictors for starting depot administration of risperidone in chronic users of antipsychotics Journal of Clinical Psychopharmacology December 2008, 28(6), 625-630

Antipsychotics for young people

Atypical, or second-generation antipsychotics are considered to be the standard treatment for children and adolescents with early-onset schizophrenia and schizoaffective disorder. However, the superiority of atypical antipsychotics over older, first-generation antipsychotics has not been demonstrated. Researchers from a number of different U.S. universities randomly assigned 116 children to receive either the second-generation antipsychotics olanzapine or risperidone or a first-generation drug molindone. Molindone had a better response rate (50%) than olanzapine (34%) or risperidone (46%) although this difference was not statistically significant, and there was no difference between the drugs in terms of symptom reduction. Olanzapine and risperidone showed the greatest risk of weight gain and other metabolic side effects while molindone led to more of the participants saying they suffered from akathisia, an unpleasant feeling of fidgetiness and an inability to sit still.

Sikich, Linmarie ... [et al] - Double-blind comparison of first- and second-generation antipsychotics in early-onset schizophrenia and schizoaffective disorder: findings from the Treatment of Early-Onset Schizophrenia Spectrum Disorders (TEOSS) Study American Journal of Psychiatry November 2008, 165(11), 1420-1431

New web site for mental-health medication

A new website Choice and Medication has been set up with the aim of offering service users and their carers access to comprehensive information and advice on mental-health conditions and medication groups. The website has been produced by the United Kingdom Psychiatric Pharmacy Group, the College of Mental Health Pharmacists, the Pharmaceutical Schizophrenia Initiative and the National Institute for Mental Health in England. It contains information on over 100 mental-health drugs, 17 mental-health problems, tables comparing the main treatments used and how the drugs are thought to work.

http://www.choiceandmedication.org.uk/en/

Infestations, delusions and medication

Delusional parasitosis (DP) is a rare but debilitating condition characterized by the false belief that one is infested by parasites, mice and vermin. It occurs particularly in middle-aged or elderly men who live alone. Primary DP occurs on its own, whereas secondary DP occurs in conjunction with another mental or physical health problem. A review of 63 case studies looked into the effectiveness of second-generation antipsychotics (SGAs) in treating DP. It found that the drugs were effective after about 10 days with the maximum effect occuring after 6 weeks. For those people who stuck with treatment for 8 weeks all cases responded at least partially. Partial or full remission was reached in 69% of the situations where an SGA was introduced. Secondary DP was more likely to respond to SGAs than primary DP. Risperidone and olanzapine were most widely used and resulted in full or partial remission in 69 and 72% of cases respectively. More research is needed into this topic as such reviews of case studies are considered less reliable than other research.

Freudenmann, Roland W. and Lepping, Peter - Second-generation antipsychotics in primary and secondary delusional parasitosis: outcome and efficacy Journal of Clinical Psychopharmacology October 2008, 28(5), 500-508

Drugs, aggression and schizophrenia

Recent research into schizophrenia has focused on some of the cognitive deficits associated with the condition which can have a greater impact on everyday activities than psychotic symptoms and have also been associated with violence. Some studies have suggested that second-generation antipsychotics are more effective at tackling cognitive deficits than earlier drugs while others have reported no advantage. Researchers in the U.S. studied 100 physically-aggressive inpatients with schizophrenia. A third were given clozapine, a third olanzapine and a third haloperidol. Olanzapine was much more effective at reducing participants' cognitive problems. In participants taking olanzapine - but not the two other drugs - improvements in cognition were associated with a reduction in violence. Clozapine was also found to markedly reduce violence but without improving participants' cognition.

Krakowski, Menachem I., Czobor, Pal and Nolan , Karen A. - Atypical antipsychotics, neurocognitive deficits, and aggression in schizophrenic patients. Journal of Clinical Psychopharmacology October 2008, 28(5), 485-493

Antipsychotics - who wins in the generation game?

So-called 'second-generation' antipsychotic drugs have traditionally been seen as providing the same level of effectiveness as first-generation ones with far fewer side effects. However, comparisons have usually been made with a highly potent first generation drug such as haloperidol. Researchers at the University of New Mexico, U.S. looked at trials which compared second-generation antipsychotics with less powerful first-generation ones and found that the effectiveness and side effects of the two types of drugs were comparable. The authors of the study concluded that clinicians should look at the unique pharmacological and side effect profile of each drug before making prescribing decisions.

Bonham, Caroline and Abbott, Christopher - Are second generation antipsychotics a distinct class? Journal of Psychiatric Practice July 2008, 14(4), 225-231

Fitness to drive and mental-health problems

Mental health problems are characterized by alterations in thinking, attention, concentration, decision-making abilities, mood and behaviour and can have far-reaching effects on a person's ability to function. One such effect is on people's ability to drive and a review of the literature looked into fourteen studies on this to weigh up the evidence. In eight of the studies mental illness was linked to higher traffic accident rates. Some psychotropic drugs had the potential to affect fitness to drive, especially in the starting phase of treatment or when adjusting medications. SSRIs (Serotonin Specific Reuptake Inhibitors) improved some of the skills needed for driving. Newer antipsychotic drugs improved cognitive skills but these improvements did not translate into driving-related skills.

Menard, Ingrid and Korner-Bitensky, Nicol - Fitness to drive in persons with psychiatric disorders and those using psychotropic medications: a systematic review Occupational Therapy in Mental Health 24(1), 2008, 47-64

Antipsychotic use soars in children

Research comparing the prescription rates for antipsychotic drugs for children in the U.K. and the U.S. has found rates soaring in both countries. The drugs were prescribed at a rate of 4 per 10,000 children in 1992 but this had increased to 7 per 10,000 by 2005. In the U.S. the rate of prescription increased from 23 per 10,000 in 1996 to 45 per 10,000 in 2001. Most of the drugs were not officially approved for children but they were used to treat autism and attention deficit disorder. Side effects of the drugs can include weight gain and heart problems and there is little long-term evidence that the drugs are safe.

You can find out more about this research at

http://psychcentral.com/news/2008/05/06/anti-psychotic-drug-prescriptions-soar-in-uk-children/2233.html

Treatment compliance - second generation antipsychotics fail to live up to their promise

Long-term maintenance anti-psychotic treatment remains the most reliable means of preventing relapses, minimizing mortality and illness and ensuring independent living in people being treated for schizophrenia. However, treatment non-adherence remains a significant concern with the reported rates of non-adherence varying between 24-90% depending on the kind of patients being treated. One of the causes of non-adherence to treatment is the side effects of drugs. Second generation anti-psychotics were thought to have at least partially overcome this problem as they have fewer side effects than earlier drugs. However, a review of studies into compliance with treatment for schizophrenia has found that 'the data have failed to substantiate the notion that novel antipsychotic drug use leads to improved medication compliance and favourable clinical outcomes'.

Voruganti, Lakshmi P., Baker, Laura K. and Awad, George A. - New generation antipsychotic drugs and compliance behaviour Current Opinion in Psychiatry March 2008, 21(2), 133-139

Dosage and treatment-resistant schizophrenia

Around 30% of people with schizophrenia have a treatment-resistant form of the condition which does not respond well to antipsychotic drugs. Clozapine is the standard treatment for such patients although it can have serious side effects such as agranulocytosis (a low white blood cell count) and weight gain. However, a study of 40 schizophrenia patients in the U.S. has found that it may be the higher doses at which clozapine is prescribed rather than the drug itself which makes it effective in treating non-responsive schizophrenia. The study found that another drug, olanzapine, when used at a higher dose than usual was just as effective as clozapine. The treatment-resistant schizophrenia responded more slowly to higher doses of olanzapine and clozapine than other forms of the condition taking six months for an improvement to be felt rather than six weeks which was the case for the more treatment-responsive form of the condition.

You can find out more about this research at

http://psychcentral.com/news/2008/02/19/med-dosage-vital-for-schizophrenia/1934.html